title: Which is first? The controversial issue of precedence in the treatment of male sexual dysfunctions.
abstract: BACKGROUND
  In male sexual dysfunction (MSD), the presence of sexual comorbidities is relatively frequent. However, what is still a matter of controversy is what the first-line therapy in these patients should be.
  
  
  METHODS
  Three scientists and the editor of the Controversies section, all experts in the medical treatment of MSD, present different perspectives on the use of phosphodiesterase type 5 inhibitors (PDE5), testosterone and dapoxetine in erectile dysfunction (ED), hypogonadism, and premature ejaculation (PE). The psychological aspects are discussed by an outstanding expert in psychosexology.
  
  
  METHODS
  Expert opinion supported by the critical review of the currently available literature.
  
  
  RESULTS
  Testosterone should be used before PDE5s in hypogonadal men with comorbid ED; PDE5s should be used before dapoxetine in PE patients with comorbid ED, and counseling should be offered to all subjects with MSD.
  
  
  CONCLUSIONS
  Although the answer to the question "which should be first?" is controversial in almost all MSDs, intuition, experience, and evidence should guide the choice of which treatment should be used first. This decision is highly critical in influencing the therapeutic outcome as well the patient's and couple's adherence to treatment.
authors.affiliation: School of Sexology, Course of Medical Sexology, Department of Clinical, Applied and Biotechnological Sciences, University of L'Aquila, L'Aquila, Italy.
authors.forename: Emmanuele A
authors.initials: EA
authors.lastname: Jannini
authors.forename: Andrea M
authors.initials: AM
authors.lastname: Isidori
authors.forename: Antonio
authors.initials: A
authors.lastname: Aversa
authors.forename: Andrea
authors.initials: A
authors.lastname: Lenzi
authors.forename: Stanley E
authors.initials: SE
authors.lastname: Althof
mesh_terms: D000328:Adult; D001596:Benzylamines / Q000009:adverse effects / Q000627:therapeutic use*; D015897:Comorbidity; D003376:Counseling; D019091:Critical Pathways; D004359:Drug Therapy, Combination; D004542:Ejaculation / Q000187:drug effects; D007172:Erectile Dysfunction / Q000175:diagnosis / Q000188:drug therapy* / Q000503:physiopathology / Q000523:psychology; D020249:Hormone Replacement Therapy / Q000009:adverse effects; D006801:Humans; D007006:Hypogonadism / Q000175:diagnosis / Q000188:drug therapy* / Q000503:physiopathology / Q000523:psychology; D008297:Male; D008875:Middle Aged; D009281:Naphthalenes / Q000009:adverse effects / Q000627:therapeutic use*; D018579:Patient Selection; D010410:Penile Erection / Q000187:drug effects; D058986:Phosphodiesterase 5 Inhibitors / Q000009:adverse effects / Q000627:therapeutic use*; D061686:Premature Ejaculation / Q000175:diagnosis / Q000188:drug therapy* / Q000503:physiopathology / Q000523:psychology; D017367:Selective Serotonin Reuptake Inhibitors / Q000009:adverse effects / Q000627:therapeutic use*; D012725:Sexual Behavior / Q000187:drug effects; D013739:Testosterone / Q000009:adverse effects / Q000627:therapeutic use*; D016896:Treatment Outcome
chemical_list: D001596:Benzylamines; D009281:Naphthalenes; D058986:Phosphodiesterase 5 Inhibitors; D017367:Selective Serotonin Reuptake Inhibitors; D013739:Testosterone; C080598:dapoxetine
keywords: Dapoxetine; Flowchart; Precedence; Sildenafil; Tadalafil; Testosterone; Vardenafil